2923 Sandy Pointe, Suite 6, Del Mar, CA 92014-2052

Yes, I want to become a sponsor of GLITSE and support your efforts to promote the education and treatment of eating disorders.

Remember, every contribution helps!

Please print this form and mail or fax it to the address/fax listed above. Thank you.

Individual/group donation: $__________

Name: ________________________________________________

Address:__________________________________________________

City: _________________________________________________

State:____________________________________________________

Zip:______________________________________________________

Daytime Phone number: ________________________________

Evening phone number: (optional)___________________________________________

Email: (optional)_____________________________________________

Please charge my visa/mastercard:

Account number: ____________________________________________

Expiration Date: ____________________________________________

Billing Name: _______________________________________________

Billing address: _____________________________________________

Amount to be charged: _______________________________________

Signature: ________________________________________________

_____My check is enclosed. Made payable to The 1-800-THERAPIST Network. We are not a non profit organization.  Your donation would not be tax-deductible.

Mail to: 2923 Sandy Pointe Suite 6 Del Mar CA 92014. 

Thank you for joining the fight.............